Providers Using EHRs to UpCode–Shocking, Just Shocking

By October 1, 2012 Commentary

The process of reimbursement by public and private health care payers involves providers developing a bill or claim and submitting it.  The bill typically must have both diagnostic codes that indicate what was wrong with the patient and procedure codes that indicate what the provider did.  During most of the modern insurance era, providers have not had systems that effectively linked their clinical records, which were typically paper, and their administrative systems, which often were computer based and which handled the billing functions.  Reimbursement amounts can vary significantly depending on various patient diagnostic and other characteristics, particularly various comorbidities or conditions.  With the advent of more wide-spread use of electronic health records, the ability to link clinical information with billing processes becomes much easier.  Couple this with the now well-proven notion that providers are economically motivated creatures, as we all are, contrary to the long-standing position of the medical profession that it is solely interested in and motivated by patient welfare, and you have a clear opportunity for some coding mischief to maximize reimbursement.  A report from the Center for Public Integrity suggests that this is happening.  (CPI Story)

The CPI analysis focused on Medicare and identified a number of areas in which the use of electronic medical records has facilitated coding that leads to higher reimbursement, usually because the patient is identified as more complex and therefore needing a higher level of service.  Billing and EHR vendors encourage the practice as a way of creating a higher return on investment for their products and services.  There may be some outright fraud, where providers put false information about the clinical characteristics of a patient or what was done for the patient into the EHR, but more often they are just being more “comprehensive” putting every little detail in, whether relevant or not, and however marginal.  Cut and paste and checklist documentation features make this very easy.  This is not a new problem; if you read the lengthy backgrounds to every recent annual release of the CMS hospital and physician payment rules you will see a “behavioral” downward adjustment attributed to “improved” coding by providers that does not reflect any actual need for more intensive services for the patient.  Whether there is any net savings from more health information technology was already greatly in doubt; when the added reimbursement from up

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